By: Dr. Maxine Theriot MD
Diabetes Is An Epidemic In The United States! It has become so large of a problem that 38.4 million people or 11.6 % of the US population are estimated to have it; and 97.6 million people currently are pre-diabetic. The economic burden associated with this disease has sky-rocketed to the tune of $307 billion dollars a year in medical costs and $106 billion dollars a year in lost productivity. 1
The impact of diabetes in minority populations is even more alarming in the United States. The prevalence of diagnosed diabetes is greater among those with less than a high school education. This number becomes incrementally smaller when higher levels of education are obtained.1 But the reason minority communities should be especially concerned is because the overall prevalence of diabetes is highest among them. Although anyone can develop a diabetic foot ulcer, Native American, Hispanics and African Americans are more likely to develop them. 1
In the United States, diabetes is the leading cause of non-traumatic amputations which is most often preceded by a diabetic foot ulcer (DFU). Sixty percent of diabetic lower extremity amputations are preceded by a DFU.2 Having diabetic peripheral neuropathy places these individuals at high risk for non-healing ulcers. Not just because of the loss of protective sensation which helps in avoidance of re-injury, but because of the underlying pathophysiology of a faulty healing mechanism, they are at an increased risk for limb-loss.3 These DFUs manifest with a chronic inflammation pattern which has been detected within 3 days of initial onset. This pattern of healing is not seen in non-diabetic acute wounds of the foot. Poor glycemic control, repetitive trauma with exposure to micro-organisms in an open wound due to neuropathy and small vessel arterial disease, leads to impaired healing, which leads to infection and tissue death.3 With the diabetic host having a poor immune response, this puts them at increased risk for sepsis and death, making an amputation often a medical emergency.
Lessening The Likelihood Of a DFU
Since the minority populations have a higher incidence of diabetes, first knowing who is at risk for diabetes is important within that subset. Questionnaires on symptoms related to diabetes, family history, personal activity patterns and current weight along with blood glucose checks and hemoglobin A1C levels can help in detecting those who are pre-diabetic or who may already have diabetes. One quick resource for patients can be found at www.doIhaveprediabetes.org to determine if they are at risk for pre-diabetes.4
Here is the good news: it is possible with small steps to reverse prediabetes-and these measures can help individuals live a longer and healthier life. Programs are available for pre-diabetics who with education, can make adjustments in lifestyle to help prevent full development of diabetes.4
The best thing for those who are at high risk for the disease to do is to contact their physician to determine if any additional testing is needed. Those who are newly diagnosed with diabetes should seek the advice of their physician and with the detection of neuropathy should follow-up with a podiatrist and be encouraged to perform daily foot checks.
Dealing With A Diabetic Foot Ulcer?
Because of the increased risk for amputation, immediate care should be sought. DON’T DELAY REFERRAL to a qualified wound care provider! Time is of the essence to save a limb and a life. Access to timely care is often a challenge in minority communities because of health care disparities. Sometimes this population’s care falls through the cracks so to speak in medicine. These patients should be referred to a comprehensive wound center, a certified wound specialist physician or podiatrist who is trained in wound care. Comprehensive wound centers through the use of standardized evidence-based clinical practice guidelines are viable resources because here patients have access to proven interventions not commonly found elsewhere. They will have treatment plans that may include, where necessary, surgical debridement, application of negative pressure wound therapy, placement of advanced cellular and/or tissue-based products, hyperbaric oxygen therapy and total contact casting which is the gold standard for off-loading DFUs while keeping the patient ambulatory.
Conclusion:
Diabetic foot ulcers are a challenge with severe consequences if not treated correctly and are more prevalent in minority populations. When DFU’s are identified, early intervention is key to improving successful healing. Patients with diabetic neuropathy or severe peripheral arterial disease who are at great risk for developing ulcers should be identified and education given regarding reduction of risk factors such as keeping good glycemic control, and performing regular foot inspections for changes in temperature, swelling, calluses, breaks in the skin or other abnormalities. Other risk factors under their control should also be addressed like smoking cessation, wearing proper fitting socks and shoes and proper nutrition through wholesome food intake and adequate hydration with water intake. Once an ulcer has formed, timely referral to a specialist trained in the care of diabetic foot ulcers is imperative for increased success. Sometimes immediate referral to the hospital emergency department is necessary for admission to control an infection related to the diabetic ulcer. And effective communication with the attending hospitalist, and inpatient care coordinators, for timely referral to either an outpatient comprehensive wound center upon discharge home, or to a facility with a qualified wound specialist if the patient is unable to return home, is necessary for continued high-quality care.
REFERENCES
1.National Diabetes Statistics Report, 2017 www.CDC.gov
2.www. CDC.gov/diabetes
3.Reiber G, et al. Causal pathways for incident lower extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999: 22:157-162
4.www.Doihaveprediabetes.org
